The purpose of this blog is to gather information about how to support caregivers of children. The quality of the caregiving relationship in infants and young children, central to the healthy development of the growing child, can be enhanced by attention to the caregivers in the form of education and other support. This blog will become an archive for information on these issues.

Monthly Archives: May 2012

Beebe presented her dyadic systems approach to face to face interactions – key domains of interaction – facial mirroring, vocal rhythm coordination, distress regulation. Dyadic systems view of face to face interaction informs nonverbal communication across the lifetime. These patterns of communication become organized into predictable, contingent interaction sequences that that generate expectations of each other’s behavior in the relationship. All this occurs in the realm of procedural knowledge. Heller and Haynal study.

Study of mother-infant (M-I) face to face interaction with split screen videotaping, videotape with one camera on each partner, second by second coding. Code orientation, touch, vocalization, facial expression, etc. Studying mothers and infants focuses on what goes on in the interaction outside of language.

Dyadic systems model proposes that all face to face interactions are simultaneous product of self and interactive regulation. DS view is that the way you co-construct relatedness is unique for the dyad; it respects the uniqueness of the individual and also of the dyad. How the mother responds to the baby partly is a function of how she regulates herself and how the baby responds to the mother is partly a function of how the baby regulates himself. The degree of the stability of the moment to moment behavior is a measure of an individual’s self-contingency [rhythm of regulation]. How does the rhythm of one partner affect the rhythm of the other? Mothers who over-stabilize themselves are less able to track their babies because they are so involved in regulating, out of awareness,[attentive to] their own state, whereas mothers who are more flexible in degree of self-predictability are better able to track their babies. The organization of the dyad is within and between. The key point is that the rhythm within your body that you think of as your own is partly organized by how you are related to your partner. This idea of the emergence of the “self” from the experience of being in a relationship is an organizing principle of the course and was repeated in the presentation by Peter Fonagy later in the weekend.

Infants are able to detect regularity and perceive contingencies. They predict when events will occur. This results in expectancies. These contingencies can be in facial expression, gaze, every communication modality [many things]. They occur in a split second time frame. It is usually the baby who breaks the gaze in gaze contingency. The degree of self and interactive procedural contingencies in an infant-mother pair is affected by the mother’s anxiety, self criticism, dependency, and depression post-partum; and these contingencies are correlated with attachment. Mothers with post partum depression may vigilantly coordinate with [look at] the baby’s face , through corresponding facial changes of her own, while not attending to the baby’s focus of attention [intention, what the baby is doing.]

The commonest mother-infant therapy situation is one in which the mother cannot tolerate the normal interruptions of gaze aversion the baby initiates to self regulate. If the mother pursues, calls, chases, this stresses the baby and makes it harder for the baby to look back at the mother. Mothers often feel rejected when this happens. One way to deal with this therapeutically is to explain to the mother, “This is the way babies work” and explain the baby’s need to gaze away to regulate himself before he looks back. Beebe says that “the baby’s agency is in the co-construction of relatedness”. She describes what she calls the “chase and dodge” situation in which the baby tries to turn away momentarily to self regulate and the mother follows him, stressing him further.

The caregiver can give the distressed child a structuring rhythm, keeping the volume low but a predictable pattern with a little variation, and put her hand on his belly or make her hand available so that the baby can use it for self-soothing.

Problems occur when there is (1) teasing of the baby by the caregiver, such as when the mother repetitively puts her finger or the nipple in and then takes it out, without any connection to the baby’s cues; (2) mutually escalating over-arousal; and (3) when mother denies the baby’s distress and smiles or looks surprised. (4) mothers look away more from the baby’s face, pays less attention to the infant who is distress; (5) mothers “loom” into the baby’s space.

When Beebe works with a mother and videotape, she asks “what the baby feels” at a particular point in the tape, and if the mother’s response is incorrect, she will say something like, “Well, actually, I think what he is feeling is X.”

Beebe showed us many fascinating films of mothers and infants. She said that in her clinical work with mother-infant pairs she “tries to link three stories – the story of the complaint, the story of the nonverbal, and the story of the parents’ histories.

Claudia Gold, a recent graduate of our program and now the author of the blog, http://claudiamgoldmd.com/, and the celebrated book, Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and Other Everyday Behavior Problems by Seeing the World Through Your Child’s Eyes, 1st Da Capo Press, ed. 2011, was our last speaker of the weekend. She talked to us about how the study of psychoanalysis, the mentorship of Peter Fonagy and the research group at Yale, and her participation in the UMB IPMHC Course helped her move from a career as a primary care pediatrician to a career as a behavioral pediatrician with a specialty in mentalization.

Reminding us that primary care clinicians have the largest professional interface with young children and their families and have relationships with these children and families over time that involve implicit trust. Yet, whereas 30% of their practice involves emotional or behavioral concerns, these pediatricians have limited knowledge or tools – behavior management, parent training, and medication – to deal with them. Considering this challenge, Claudia made a paradigm shift in her own practice and now in the wider world of parents and children, by identifying her primary task as promoting reflective functioning. By “holding a child in mind”, Claudia attempts to teach parents to be curious about the meaning of their child’s behavior, to have empathy for them, to contain and regulate their child’s behavior and also to better regulate themselves. In addition to her practice in Western Mass., Claudia is beginning to work on an Early Childhood Social Emotional Health Program at the Newton-Wellesley Hospital.

The way this kind of learning occurs helps us understand how the knowledge communicated between parent and child becomes “what is known” and “how it is done” in a large group of people, and then what about this gets passed down over generations. This does not occur through intentional, cognitive learning, but instead happens through the use of “ostensive communication cues”. These cues include such behaviors as eye contact, turn taking patterns, and specific tones of voice such as the falsetto voices mothers use to talk to their babies referred to as “motherese”. Fonagy explains that what establishes these ostensive cues most reliably is the same thing that generates secure attachment – sensitive, attuned behavior towards the baby, giving the baby the sense that the adult is trustworthy and therefore that the information is reliable. Fonagy stresses that all human life is built on social knowledge, and that if you deprive the child of “epistemic trust”, you deprive him of the possibility of benefiting from what he needs to succeed in the society into which he was born. Relationships are absolutely crucial to the transmission of cultural knowledge.

The Implications of Mentalization for Helping People Grow (in psychotherapy or other ways)

When you are with someone who is not mentalizing, it is impossible to have a rational discussion with him. That is because he has a rigid position that is heavily influenced by his own internal beliefs and he cannot bring an open mind to the conversation. For example, if he perceives himself as a victim, he will see everything that happens to him as victimization by a cruel world, and if you try to explore with him how he might have contributed to the outcome by some of his actions, he will not agree and will probably feel victimized by you. This is fairly characteristic of many adolescents, and actually occurs in all of us if we are stressed to an extreme enough degree. One of the ways I see “normal” people let go of their mentalizing is when that person is a parent who is desperately worried about his child. In that case, the internal perception of helplessness in an uncaring world (if people really cared, they would do something!) is so overwhelming that the parent cannot imagine a situation in which there is nothing to be done but wait. Another situation is in high conflict divorces in which each parent perceives him or herself as the victim of the other, and cannot empathize with the other at all.

Fonagy stressed the need to insist on a mentalizing process in therapeutic or other helping engagements. This means that if the person you are working with insists on taking a “non-mentalizing”, or irrational and highly personalized point of view, you must focus on bringing the conversation into a mentalizing one instead of just “hearing out” a lengthy non-mentalizing explanation from the other person. That is because the “hearing out” is deceptive in that it involves the person reestablishing his rigid point of view instead of presenting an opinon that is open to alternative perspectives. Fonagy points out that when your interactive partner is not mentalizing, you stop mentalizing!

Most of the patients Fonagy has studied from the point of mentalization have a diagnosis of Borderline Personality Disorder, but he makes the point that we are all vulnerable to lose our capacity to mentalize under extreme stress. This personality disorder (BPD), he thinks, is a developmental problem, in other words, the failure to develop a competency (mentalization) that it is possible to still develop. Twin studies suggest that it is heritable and it is also associated with early maternal separation and abuse (Belsky, Caspi, Arnseneault, Bleidorn, Fonagy et al, 2012, Dev. and Psychopathology). This suggests that children with a family history of mental illness (any kind) and early parental separation, neglect, or abuse, should be the primary focus of attention of mental health clinicians.

Fonagy reiterates the genetics and early environmental influences activating the attachment system and disrupting mentalization, giving way to a disorganized sense of self and three problematic activities:

1.Psychic equivalence – in which a person thinks that just because they are thinking something, it is automatically true. Flashbacks are an extreme example, and intolerance of alternative perspectives is a more ordinary one.

2.Pretend mode – the mental world is decoupled from external reality. For example, a woman can be completely convinced that a man in her office is infatuated with her even though he has never given her evidence of this.

3.Teleological mode – physical action is seen as the only way to modify someone else’s mental state. An example is when a person insists on concrete evidence of your caring for them – including extra sessions or telephone calls or physical touching.

1.Take a stance of active questioning and “not knowing”. That means that you do not presume to know what is going on until the other person explains it to you. While “not knowing”, you gently insist on alternative perspectives. (“Of course, I don’t know, but when I think about it, it occurs to me that X might be happening instead of Y.”)

2.Monitor your own mistakes. That means acknowledging your inability to really know what is in the other’s mind and apologize for your mistakes.

3.Empathy.

4.Curiosity about the other’s experience.

5.Staying in the present instead of moving to the past.

6.Lower arousal by bringing it back to you: “What have I said that bothered you?”

7.Quickly step back if the person seems to be losing control.

8.Highlight the experience of “feeling felt”.

9.Identify a break in mentalizing and “rewind” to the moment before.

10.The main idea is to “create a space” in which the rhythms of mentalizing can occur, a safe place where you collaborate in creating a more flexible and adaptive meaning about what is bothering the person.

Fonagy has a new book out about how to understand mentalizing and how to practice it:

I will begin with the presentation by Dr. Peter Fonagy on “Mentalization”. I will give the summary in two parts. This is the first.

Fonagy started by “tracing the developmental roots of mentalization”. In fact, he began even before by tracing the evolutionary roots. Pointing out that humans have the skill to perceive intentionality in one another’s acts, he noted that even chimpanzees cannot reliably distinguish between when someone accidentally drops an object and when he intentionally lets it fall. I was pleased to hear that dogs actually are very good at that. I imagine this is because dogs were domesticated so early in evolutionary history and have learned things from humans that then become inherited. The capacity to mentalize has also been argued to account for other differences between humans and ages – the social emotions of embarrassment, shame, and guilt, and spirituality and art. It is interesting that mentalizing, the capacity to understand acts in terms of intentions, emerged in good times but not in times of hardship. The most persuasive argument for this, Fonagy says, is that when the environment does not put pressure on us from the point of view of survival, the only way our genes could survive is through outsmarting other people!

A working definition of mentalization: “Mentalizing is a form of imaginative mental activity, namely, perceiving and interpreting human behavior in terms of mental states (for example, needs, desires, feelings, beliefs, goals, purposes, and reasons).

There are shared neural circuits for mentalizing about the self and about the other. Mental states represented in the brain about the self are co-located with mental states represented in the brain about the other. They are mediated by the same part of the brain. The development of these capacities occurs in tandem. An infant’s capacity to understand another arises from their ability to understand themselves, which in turn arises from the other’s communication of their ability to understand the infant, in a beautiful cycle. We initially learn to mentalize in our relationships with our parents. The parents’ capacity to mirror effectively her child’s internal state is at the heart of affect regulation. The infant is dependent on contingent responses from the caregiver, which in turn depends on the caregiver’s ability to be reflective about her child as a psychological being. Failure to find the self in the mind of the other can result in a profoundly distorted self-representation.

Mirroring: The caregiver “mirrors” the infant’s affective states, in a “marked” (not totally exact but recognizable) way and that makes the child feel known or sensed in the caregiver’s mind, giving rise to an emerging sense of self as a person with feelings. The capacity of the caregiver to mirror the infant’s states is correlated with the child’s capacity for pretend play at 3-years. This is why kids who are neglected have trouble with self-representation and often don’t know what they are feeling. Some infants are difficult to mentalize and some caregivers (CG) are unable to understand them, and it becomes a cascade of trouble. There are lots of ways this process can go wrong; it is a vulnerable system.

The development of mentalizing has bidirectional influences. Poor affect regulation in the infant makes sensitive caregiving difficult. The inability to mentalize disrupts the attachment relationship, which undermines further development. The very process that could help the child to overcome these interpersonal challenges – psychotherapy – is sometimes undermined by the difficulties in the attachment system. An example is the children who cannot allow the therapist to engage with them in therapy and the therapist misattributes this failure as intentional behavior in the children. Sometimes children cannot benefit from benign new relationships because they disrupt them. (This reminds me of the traumatized children Bruce Perry talks about.)

Fonagy believes that genetics has a great deal to do with this. This genetic influence is not straightforward, however. Most psychopathology involves an individual losing calibration over what is happening in their brain. That is, there is neural activity but the process (secondary process) by which you attribute meaning to that activity, has gone wrong. What has an individual been programmed to do I that situation? The individual is programmed to do what humans did to originally get that capacity – talk to somebody. Freud made a contribution by making a profession out of this. The process is an evolutionarily driven process. We try to understand our mental experience through attributing meaning to it. Mentalizing is the process. Attachment is involved. Compassion is the valence.

There are many studies that demonstrate the early awareness of infants’ mentalizing capacities. And infants are also biologically wired to think that the world behaves in a decent way. Violations of these expectations are toxic because not only do they teach inappropriate content but they undermine mechanisms for the social acquisition of knowledge and the emergence of the agentic sense of self. The role of the environment is to facilitate a biologically prepared process for the acquisition of knowledge. If the environment is good enough the process will become active. But if it is systematically hurtful or depriving it won’t. The significance of disconfirming legitimate expectations – The more we learn, it is the disconfirming of legitimate biological expectations that is important. The system has been constructed to ignore the bad experiences as part of the culture because of the way the CG behaves. If the CG behaves badly, then the child will come to expect bad things from the culture.

On Friday I spoke with two friends from Love and Hope. One of them, K, is a young teacher who is giving tutoring sessions to some of the children. She will be at the Home for two years. Two of the children she is tutoring individually are the two boys of 8 and 9 years old that I wrote about in a previous posting. I am particularly concerned about these boys, who are both struggling in school and seem isolated and unhappy. I was glad that she would be helping them with their academic skills and their homework, because school is such an important source of self esteem in school aged children. In addition, it seemed to me that offering them another relationship with an adult whom they could come to trust and care about could make an important difference at this time in their lives, could change their negative sense of themselves and give them hope.

In my last visit, I spoke with the psychologist and social worker about beginning individual therapy sessions with these children. In this conversation, I recommended to K that she add 15 minutes of “play” to the end of each tutoring session. By play I meant playing a game and not talking about anything serious unless the child brought it up naturally in the course of the game.

It is easy to underestimate the importance of play and the role it has in child development. A simple game of cards involves many features that scaffold growth. For example, when the card players move back and forth across the play space as they draw and place cards, they are creating coordiinated rhythms with their bodies, what I call a “do se do” pattern. When they speak, they make coordinated rhythms with the duration of their vocal turns and with the length of the pauses they take as one finishes speaking and the other begins. These coordinated rhythms are implicit; they occur out of awareness in the micro-process, the second and split second time frame, but they underlie the building of trust in a relationship. Synchronous rhythms between two people can generate a sense of comfort and security. They can form the basis of reciprocity.

In a larger time frame, a game can generate trust through the notion of “fair play”. The adult proves herself trustworthy by not taking unfair advantage of the child in the game, not cheating. She demonstrates tolerance by her patience with the child as he learns a new game or when he is not as adept as she at playing. She shows compassion when the child loses and even offers an example of “good” winning by expressing pleasure but not gloating nor superiority. You can see why I recommend playing a game.

I will follow up with K to see how this goes.

In the next post I will begin the summary of the Infant Mental Health Course weekend, which was wonderful.

On Friday I spoke with two friends from Love and Hope. One of them, K, is a young teacher who is giving tutoring sessions to some of the children. She will be at the Home for two years. Two of the children she is tutoring individually are the two boys of 8 and 9 years old that I wrote about in a previous posting. I am particularly concerned about these boys, who are both struggling in school and seem isolated and unhappy. I was glad that she would be helping them with their academic skills and their homework, because school is such an important source of self esteem in school aged children. In addition, it seemed to me that offering them another relationship with an adult whom they could come to trust and care about could make an important difference at this time in their lives, could change their negative sense of themselves and give them hope.

In my last visit, I spoke with the psychologist and social worker about beginning individual therapy sessions with these children. In this conversation, I recommended to K that she add 15 minutes of “play” to the end of each tutoring session. By play I meant playing a game and not talking about anything serious unless the child brought it up naturally in the course of the game.

It is easy to underestimate the importance of play and the role it has in child development. A simple game of cards involves many features that scaffold growth. For example, when the card players move back and forth across the play space as they draw and place cards, they are creating coordiinated rhythms with their bodies, what I call a “do se do” pattern. When they speak, they make coordinated rhythms with the duration of their vocal turns and with the length of the pauses they take as one finishes speaking and the other begins. These coordinated rhythms are implicit; they occur out of awareness in the micro-process, the second and split second time frame, but they underlie the building of trust in a relationship. Synchronous rhythms between two people can generate a sense of comfort and security. They can form the basis of reciprocity.

In a larger time frame, a game can generate trust through the notion of “fair play”. The adult proves herself trustworthy by not taking unfair advantage of the child in the game, not cheating. She demonstrates tolerance by her patience with the child as he learns a new game or when he is not as adept as she at playing. She shows compassion when the child loses and even offers an example of “good” winning by expressing pleasure but not gloating nor superiority. You can see why I recommend playing a game.

I will follow up with K to see how this goes.

In the next post I will begin the summary of the Infant Mental Health Course weekend, which was wonderful.

A Chinese colleague wrote to me about a young mother in Shanghai who has a baby girl born with Mondini Dysplasia.

Mondini dysplasia is a type of inner ear malformation that is present at birth, in which affected individuals have one and one half coils of the cochlea instead of the normal two coils. It may be unilateral or bilateral and can cause sensorineural hearing loss and a predisposition to recurrent meningitis. Mondini dysplasia may be associated with other ear malformations or other syndromes. Treatment options include surgical repair of the defect in an attempt to prevent meningitis, hearing aids, and cochlear implants.

My colleague in Shanghai asked how this mother could help her little girl during the years before undergoing a surgical operation to “build” a new ear (she was told that this operation can only be done around 14 years old). She worries that this defect may result in “disorders of sensory integration”. My colleague describes the mother as a strong and intelligent woman who is willing to learn about the problem and do everything she can to support her daughter’s healthy development.

I responded to my colleague that I would like to know more about her friend’s child’s problem – the degree of severity, whether it is unilateral or bilateral, what her particular deficits are, and what her strengths are – so that when I write something about it I am sure to address her particular questions. Actually, what would be best is if she could ask the mother what questions she would like answered.

Before hearing from the mother about her specific questions, I will inquire of my colleagues who might treat children with Mondini dysplasia, and also those who work with children who have more general sensori-perceptual problems. In the meantime, the most important recommendation I have for her friend is to build a loving relationship with her child and to gather around her people to support her while she does that.

My colleague, Debbie Bausch, an O.T. who specializes in sensori-perceptual disorders, responded: “When I looked up Mondini Dysplasia, the site mentioned that there could be absence not only of the cochlea but possibly the inner ear- semi circular canals, etc. If this were the case, I would suspect a greater possible degree of SPD (sensori-perceptual disorder). The major issue would be balance deficits- having difficulty knowing where your head was in relation to gravity. In order to answer this we’d have to know more about the specifics of how Mondini dysplagia affected this child including whether it is unilateral, bilateral, etc.”

I am hoping that other readers with greater familiarity with this disorder than I can send me a comment that will help this mother.

I had the pleasure of observing a preschool teacher, Lisa, with an almost 4-year old boy with autistic spectrum disorder, Max, in the classroom last week. What became clear is that what is necessary with children like Max is a shift in perspective to the essentials of learning. Instead of a focus on teaching him academic and concrete skills, one could instead emphasize above all social relationships and the communication of emotions. (This is not new; Stanley Greenspan and his DIR followers to a refined degree have developed these ideas in the technique of “Floor Time”.) In the list of priorities after social relationships and the communication of emotions, is regulation – because regulation is critical but it can’t be supported outside an affectively attuned relationship. Next, it is important to place Max’s initiative in the center of the relationship; helping him make decisions, feel like an active agent in the world. Finally, you want to help Max make links between his internal states (emotional and physiological arousal states, such as calm or revved up) and his behavior. You also would like to help him make these links between other people’s feelings and their behaviors.

So, let me address my observations. I want to mention up front that these thoughts consist of my elaborations of the consultation I had with Debbie Bausch, my friend and colleague who is a DIR (“Floor Time”) O.T. and sensory perceptual specialist.

First of all, I was very appreciative that the school had gotten a swing. Regulatory breaks are so important and the swing can be a resource for many children. In the swing, Max can experience calm. Once he is calm, he can make use of person-to-person interaction, with the aim of creating reciprocity. One can ask him, “Max, shall we go faster or slower?” He can be part of the decision about how to swing – back and forth, fast and slow. That is scaffolding his initiative. When I saw him in the swing, he was calm, and he looked at me and smiled, demonstrating that he was ready for an interaction. That is a good swing for him.

The swing break was called to a close by the entrance of other children. Lisa was gentle and patient with Max in helping him make the transition out of the swing. The slow pace she used consistently during her time with Max was perfect for him. Slowing things down makes them easier to understand. That is especially true for a child with processing problems, as most children with developmental disabilities have. When Lisa and Max were putting away the swing, Max was trying hard to hold himself together. There was a lot going on for him – the stimulation of the other kids coming in and the challenge of going through the motoric, physiological, sensori-perceptual, and affective transition from the swing to standing upright and leaving the room to return to class. He used his hands in his mouth as a self-regulating behavior here and at other times during the morning. Debbie mentioned that a special hard plastic bracelet could be used for this kind of oral stimulation.

If Max were calm enough, this would be a good time to give him some more information, such as, “Max, look! The other children are coming in! We have to get out of the swing because the other children have activity time!” In general, it is good to narrate all these small, ordinary events, because first of all it is not clear that he perceives them (due to processing and attentional problems) and also because it gives you a chance, using your adult competencies, to scaffold his meaning making of the world. Of course, you always have to “read” his state to see if he is well regulated enough to take in that information. Also of course, you can never be right all the time about this. It is a messy, sloppy, business – reading someone else’s state. Yet I would bet that most preschool teachers are particularly good at reading non-verbal cues, and you will get to know Max’s cues, such as putting his hands in his mouth, squiggling around in his seat, etc., better and better.

In general, once he is calm enough to communicate, it is good to direct him into a back and forth communication. “What should we do, should we swing faster or slower?” with the swing, or, “Shall we walk or hop?” when you are walking down the hall. This could be described as a “sensory-emotional break” (Debbie Bausch).

After that, it is time to prepare him for what is coming next. What will be expected of him in the next period of time? It is good to think ahead and help him get ready. Lisa repeatedly talked to Max about what they were going to do. She bent down to his level and spoke slowly to him about going back to his classroom. She asked him what he would like to do and when he did not answer she suggested the block corner. If Max had been in a state of better regulation, he might have been able to participate in the decision that Lisa tried to engage him in, but the stress of making the transition may have gotten in the way. Debbie suggested giving him a whistle to blow to exercise his oral senses, and some heavy beanbags to throw, or to carry when he walks down the hall as an aid to regulation. Sometimes maneuvering so that you are in his line of vision (not intruding into his “space bubble”, but right there if he looks up) can help engage him in exercising his initiative. Experiment a little; it may take him longer to look at a face. Other times, slowing things down even further can help. Another thought is to back up and talk to him when he is still in the swing, calm and attentive, before moving down the noisy hall. If he is still sitting in the swing when you are talking to him about what is going to happen next, you can have ready some alternative ways of communicating to him about the next step. For example, you can have cards with pictures of the activities, in case he doesn’t respond to the words.

The main point here is that Max’s teachers will need to learn to imagine what is going on in Max’s mind. All these things going on around him during the day do not connect for him; the world is chaotic. Even inside of him it is often chaotic. His teachers will have to find answers for the question of when is he at his best, and how can they make school easier for him.

Walking into the classroom, Lisa saw that the blocks corner was occupied. She was right on target when she explained to Max that there were already “four friends” in the block corner, so that they would have to make another choice. She helped him choose a book. This was my favorite part of the observation. In the book corner, Lisa found many opportunities to teach Max about himself and his world while he was calm and regulated. As they were sitting down, Max picked up a wooden board on the bookshelf, and remarked, “Art Activity!” Lisa responded positively to his communication. I thought this demonstrated a real strength on Max’s part. I would like to think that I would have been able to join him there and say something like, “Oh, Max, yes! Art Activity! I remember when you made X or did Y in Art Activity!” But I do not know for sure if I would think of it. That is why it takes practice to “imagine Max’s mind”. Once you get better at it, you more naturally think of joining him in those moments and expanding a little on what he has started. In those cases you are helping him make more sense of his world than he could do by himself, using your adult competencies to scaffold his meaning making, and simultaneously supporting his agency by recognizing what he has done and taking it a step further.

Then, Janie came over, holding a book. This might be an opportunity for teaching about relationships and about the rest of the world in that context. For example, “Oh, look! Janie is coming over! Look what she has! Shall we ask her if she wants to read a book with us?” Or one could do it an even easier way for Max: “Janie, Max and I are going to read a book. I am going to ask Max if he would like you to read a book with us. Max, would you like Janie to read a book with us?” The difference is that by addressing Max first you are taking the social pressure off him and also previewing the central point of the social communication – does he want another child to join. It is also a good example of the way I work with Gil Kliman’s “Reflective Network Therapy”, making use of the classroom to help Max make sense of his experience of himself with a peer.

Another thought is that when Max is asked to choose a book, the choice may overwhelm him. That is when you can make it easier for him by taking two books out and asking him to choose between the two. By limiting the choices but emphasizing his choosing, you scaffold the processing task he needs to use his initiative.

When Max reads the book, he is calm and totally engrossed. He has chosen a book with pictures of his class. He recognizes each classmate by name and points to him or her. This, again, is a significant strength. One of the hallmarks of his disorder though, his lack of looking at Lisa’s eyes, interferes with his taking in other crucial information. He looks only at the book. That is a less challenging way for him to take in information than by looking at the constantly changing facial expression of a person. It would be good to gently but persistently try to get him to look at your eyes. There is a wonderful point in the book reading when Max points to the eyes of the child in the book and then at the eyes on the figure on his shirt, and Lisa says, “Does Max have eyes?” pointing to Max’s eyes, and then, “Does Lisa have eyes?” At that moment, probably the best moment in the observation, he looks directly into her eyes and sees her smiling at him. This of course is what he misses when he doesn’t look at the other person’s face. That was truly what I call a magic moment. One would like to repeat that magic moment. One way you could do it is by pausing now and then and making a big expression with face and voice say, “Oh, yes! That’s Jacob! I remember you playing ball with Jacob!” or something like that. If you look at his face, you will see lots of little facial expressions that you can comment on, again enhancing his awareness of his own inner feelings, such as, “Oh, Max. I can see that you like that picture!” or “Max, I think you do not like that picture!” In the observation, Lisa uses Max’s pointing to pace their activity, a great way to support his initiative.

Then little Janie barges in and sits in between them. Interestingly, Max does not seem to notice that she is there for quite a while. Is this because he cannot attend to these two things at once? Is it because he cannot easily scan the periphery and return his gaze to the page of the book? I don’t know, but one could help him take in the information with words: “Max, Janie is coming to sit with us. Is it OK that she sits in between Max and Lisa?” When Max notices Janie, he gives her a direct gaze and a smile; then, he leans over against her, and she squeals in annoyance. It appears that Max really desires a connection with Janie but doesn’t know how to do it. This is the time, Debbie says, when the teacher could put a little weighted lap pad or pillow on his lap to give him some of the sensory input that he seems to need to regulate himself. One could also talk to him about it, “Oh, Max. You want to sit next to Janie! It makes you excited to sit next to Janie! Let’s use your pillow to help you keep calm while you sit next to Janie.” In fact, Lisa does recognize what is going on and gives him information about what he might do – “You could say, ‘Hi’.” She also gives him some pressure with her hand to help him regulate himself. Then Lisa directs Max back to the book, and in a nice attention shift, he joins her.

The next step might be to engage Janie in reading the same book. You can say, “Oh, Janie, Max knows the names of all the kids!” or “Max, Janie is wearing the same necklace in the book that she is wearing now. Look at her necklace!” then point back to the book. Not only is that working on his relationships and using the neuro-typical peer as a co-teacher, but it is also working on his ability to flexibly move his body and his attention from one point to another.

During the rest of the observation, Lisa was able to get Max to use his matching board, though he clearly was having a hard time staying regulated, and even to get him to help her pick up the cards that he dumped behind the bench (in an expression of protest). I was left thinking that this was a child with real potential growth and a teacher with real talent. On the other hand, I was also left with the clear imperative to give the teachers the recognition and support that they deserve and need with this wonderful but very challenging little boy.

This series of photographs illustrates a beautiful example of the repair of a conflict between two children, with many magic moments. E, in the blue shorts, is a 6-yo boy who hit K, the boy in the blue jeans, with a ball. The hit was most likely accidental, but K, who is 4-years old, began to cry and went to get the caregiver, L. In this photo, L is listening to E’s account of the story. A 7-yo girl, B, is the audience. In the the first photo, J has just finished voicing his complaint, and L is looking at D questioningly, waiting for an explanation.

In the second photo, E is defending himself, proclaiming his innocence of the charges. K is watching silently. B stands silently as witness. L explains that K was crying, and that E needs to apologize to K and help him feel better, even if it were an accident. B continues to stand, watching, her little hands on her hips. E is refusing to apologize to K. L is firm but gentle, her voice quiet and slow-paced. This is a magic moment, because L does not express anger or impatience, yet she persists.

In the third photo, L bends down to talk to E. E looks as if he is going to run away, and L takes hold of his arm. E is kicking his foot, rebelliously. At last, E says he is sorry, but he growls it out with a scowl. L tells him that he must say it again in a nicer way. E repeats his angry apology, and L quietly insists again that he say it nicely. This is another magic moment, because instead of getting angry, she persists in a quiet, non-reactive way. E finally says he is sorry – not exactly “nicely” – but without a growl. Here is another magic moment, in that L accepts a gesture that is less than perfect. She must have had the sense that at this point she could help bring the situation to a good resolution.

In the fourth photo, L tells E that he should give K a hug to make him feel better. This is too much for E, so in another magic moment, she opens her own arms and encloses the two little boys in a group embrace.

In the fifth photo, the embrace continues, but L is preparing to let them go. The boys are giggling.

The magic moments in this set of photos focus on L’s patience, calm, and slow pace. These factors in addition to her quietly loving attitude allow her to side-step provocation into a struggle and generate the creative solution of the group hug. As she watches the scenario, B takes in the gestalt of the repair of conflict scaffolded by an adult, including the magic moments. All three children are more likely to repeat at least one of the elements of this repair in future conflicts.

About

Alexandra Murray Harrison, M.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute in Adult and Child and Adolescent Psychoanalysis, an Assistant Clinical Professor of Psychiatry, Harvard Medical School at the Cambridge Health Alliance, and on the Faculty of the Infant-Parent Mental Health Post Graduate Certificate Program at University of Massachusetts Boston. Dr. Harrison has a private practice in both adult and child psychoanalysis and psychiatry. In the context of visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.